Student Name
Birth Date
Current School
Current Grade
Medical issues
Medical needs
Medication allergies
Food allergies
Other allergies
Special dietary needs
Additional medical information
Questions or Comments
Parent Information
Father's Name
Cell Phone
Highest Level of Education Attained
Mother's Name
Cell Phone
Highest Level of Education Attained
Student Information
Intended Student Start Date
What is the first language this child learned to speak?
What language does this child speak most often outside of school?
What language do people usually speak in this child’s home?
Is this student currently under suspension/expulsion from another school?
Has this student previously received special education services?
Is this student currently receiving special education services?
I give my consent for emergency medical treatment for my child. In the event of illness or injury requiring emergency treatment, I give permission for the school authorities to take action.
I, the parent, hereby give my consent to all photographs, audio recordings, academic work, and/or video recordings taken of me or my minor child by Annoor Academy of Knoxville staff or their designee.
Is there anyone who DOES NOT have permission to pick up student? (Please list name and relationship)
Alternative Contact / Pickup (Name and Phone number)
Financial Information
Tuition Payment Method:
Account holders name as shown on account:
Banking Routing /ABA Number:
Bank Account Number:
Credit Card Number
Cardholder Zip Code from credit card billing address:
Card Number Expires:
Electronic Signature
Upload Current Immunization Record and Birth Certificate
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